Public Health paper 5-6-08

Crisis In The Health Sector Of Caribbean Countries: The Impact Of Trade
Liberalization And The Movement Of Labour On Health Services In The
CARICOM
Marjorie Charles, PhD (University of the West Indies)
browncharles0062@gmail.com
INTERNATIONAL STUDIES ASSOCIATION
SAN FRANCISCO
CALIFORNIA
March 2008:
DRAFT. (WORKING PAPER )
DO NOT QUOTE WITHOUT PERMISSION
INTRODUCTION
Frame of Reference
Changes in the contours of the global environment occasioned by the process of
globalization, with attendant advancement in technology, communications and
transportation demand corresponding changes in the approach to global and domestic
issues. The process of globalization, fueled by the end of the Cold War and the
dominance of the political and ideological paradigm of the major powers has created a
tremendous impact on the lives of individuals, groups, states regions and the world to the
extent that occurrences in the most remote part of the world now often have a significant
effect on all other areas. As a result, domestic policies are influenced by decisions made
in the global arena. The impact is felt more noticeably in the areas of trade and finance
where the merging of financial institutions and other multinational corporations allow for
the transfer of capital and other resources across borders without important restrictions.
The process has indeed contributed heavily to the emergence of a borderless society, and
the emphasis on the liberalization of trade further facilitates such a society. The
establishment of the World Trade Organization (WTO) to provide a forum for further
negotiations on the removal of tariff barriers as well as the liberalization of other areas of
trade such as trade in services has also strengthened the creation of such a society. The
entrenchment of the liberal economic order, designed by the major powers has been the
result. Thus liberalization, deregulation, privatization and monetary and fiscal policies
have been advanced by some analysts as the most effective strategies for the
improvement of the economic condition of developing countries in particular.
Accordingly, many of these countries have embraced, whether by force or their own
volition, the policies identified, in an effort to achieve this objective. However, the
success, which was envisioned from the implementation of the policy, has not been
evident in many developing countries even within the framework of structural adjustment
programmes (Marshall1998). What has resulted is the marginalization of these countries
in the global economy and a resultant widening of the gap between rich and poor
countries. Thus the attempted integration of developing countries in the world economy
has not evidenced an improvement in the economic condition of most of them (Cohn
2000).
The liberalization of trade in services and the emergence of the General Agreement on
Trade in Services (GATS) signaled a milestone in the history of trade negotiations and
the attempts to liberalize trade in general. Its flexibility and pragmatism cannot be
understated, given that it essentially reflects the status quo and promotes the right of
governments to regulate to ensure that quality is achieved and/or maintained. Despite the
turbulence associated with the decision to include it in the agenda for liberalization
during the Uruguay Round of trade negotiations, it is now viewed as “the only
conceivable approach to devising an Agreement involving some 140
participants” (Adlung & Carzaniga 2001:13)
Since the early 1980s, international trade in services has been the focus of increasing
attention, especially at the global level. It has also been the subject of frequent intense
debates and discussions. The introduction of this sector on the agenda of the multilateral
negotiations is evidence of the increasing importance both to domestic and international
trade as well as the development of the economy. Emphasis on trade as an engine of
growth in the post- industrial era was the result of the substantial growth in the service
element of trade in goods (Koekkoek 1987). This reflects a need for technological
advancement for the production of complex manufactured goods, which in turn
necessitates the use of highly specialized servicing. In particular cases, where goods and
services are inextricably linked, services could provide the stimulus for growth in trade in
goods (Schultz 1987).
The dynamism of services in the development process has contributed to a transformation
of the world economy. This transformation is derived from the technological revolution.
Telecommunications and computer technology have thus created unlimited opportunities
for international transaction in services. This global transformation via the modification
of the service sector, as well as its impact on world trade has been credited for the
improvement in the image of services, where previously it was considered a nonproductive
sector or 'invisibles', as under GATT, where they relate to trade in goods.
The inclusion of trade in services in the Uruguay Round was done with a view to
achieving liberalization of services in the same manner in which goods were liberalized
and governed by a trade régime. Thus the liberalization of the sector within the WTO,
especially the liberalization of professional services and the movement of natural labour,
has changed the global landscape and has accorded to developing countries opportunities
for advanced economic growth. However in tandem with the economic benefits are the
costs to these economies particularly as regards the loss of significant human resources –
the brain drain.
This is applicable in particular to trade in health services, as with the liberalization of this
sector along with professional services, the migration of nurses has increased to alarming
proportions worldwide (Buchan et.al 2003). Even before the liberalization, which has
seen an increase in the movement of health personnel, the Caribbean was experiencing
mass exodus of its trained nurses to developed markets, namely the United States, and to
a lesser extent, Canada and the United Kingdom. This has also provided a spin-off
industry – that of the creation of and increase in recruitment agencies that are able to
access the “markets” of these countries to recruit nurses unchecked.
These movements have been mainly permanent, outside the ambit or scope of the trade
experience, although in recent times, the liberalization has contributed to the increase,
where recruiters now have a carte blanche to tap into the local market and recruit the best
of the best. The movement has been driven by “wage differentials between countries and
a search for better working conditions and living standards; a search for better training
possibilities; and demand-supply imbalances in the health sector between host and source
countries” (Chanda 2002; Campbell 1991; Pan American Health Organization 1997).
Trade in health services occurs within the four modes of delivery: Mode1- cross-border
trade; Mode 2 -consumption abroad: Mode 3 - commercial presence and Mode 4 - the
movement of natural persons. While trade that is facilitated through the Modes 1, 2 and 3
benefit the receiving countries to a large extent, it is Mode 4 that provides the most
worrisome problems for developing countries as they largely represent the suppliers of
nurses to developed countries, leaving their respective countries unable to cope with the
effects of such movement.
The migration of nurses is facilitated by the global shortage being experienced currently.
In fact as Buchan et al (2003) suggest, there is a demand and supply imbalance in the
nursing sector in most countries, both developed and developing. One major policy
response to this situation on the part of developed countries and some developing
countries is the exploitation of the opportunities presented by the voluntary migration of
the nurses, influenced by the factors motivating relocation. The recruitment of nurses
from developing countries is the dominant mechanism through which the shortage is
addressed. However as already stated, this lends itself to problems in the source country;
that of the inability to address their own need – mainly that of providing quality care for
their respective populations. This situation has in fact reached critical proportions in these
developing countries.
THEORETICAL CONSIDERATIONS
The issue of migration as a phenomenon in Caribbean reality must be understood within
the broader context of reasons for migration or the theories that underpin that reality.
Migration is a complex issue and the reasons for it are just as varied and complex. As
such no one theory can comprehensively explain the phenomenon. What must be
primarily understood as a “selective process” at the level of the individual. Attendant
factors include educational, economic, social and physical issues, and the impact of these
on the decision making process of the individual vary according to circumstances and the
individual’s own reality.
A theory of migration was first conceptualized by Ravenstein (1889), who postulated,
based on census data from England and Wales, the “push-pull” process. His central thesis
was that “unfavorable conditions” in the source country push people. They respond to
favorable conditions in host countries. These conditions pull them out. Thus factors
emphasizing better economic opportunities were primarily responsible for migration.
Other contributions argue that the volume of migration should decrease as distance
increases; migration occurs in stages instead of one long move; population movements
are bilateral and migration differentials influence a person’s mobility (Ravenstein 1889;
Theories of Migration 2008).
It has been argued (theories of migration 2008) that many of the dominant contemporary
theories on migration are variations of Ravenstein’s conclusions. For example Lee (1966)
focused on push factors and advocated that “intervening obstacles” also impacted the
migration process. Age and social class differentials, among others, influence response to
push-pull factors, which in turn have an impact their ability to ‘overcome intervening
obstacles’. Other factors retarding or enhancing mobility include educational level, prior
knowledge of the host country and family ties (Theories of Migration 2008).
Most modern studies of migration utilize the hypothesis of the human capital approach in
which the “differences in net economic advantages, chiefly differences in wages are the
main causes of migration” as a starting point (Hicks 1932). The migration of workers is
seen as a type of human capital (Sjaastad 1962). This is where migrants undertake a cost
– benefit analysis. They calculate the “value of the opportunities available in each of the
alternative labour market, net out the cost of making the move, compare the likelihood of
finding employment, and choose whichever option maximizes the net expected present
value of lifetime income” (Kubursi 2006: 6).
Migration costs, which are calculated, include actual expenditure involved in the
transportation of the worker and family, as well as the monetary value of the “psychic
cost”. The cost could be translated into a single payment or a ‘lasting psychological cost”
which is calculated each year. As an aspect of human capital investment, the decision to
migrated can be seen within the context of the comparison of “present value of lifetime
earnings in the alternative opportunities” (Kubursi 2006: 6)
Thus as a neoclassical approach to migration, with a narrow focus on human capital
investment, the theory advocates that migration occurs if the possibility exists to recover
their investment. Based on this, occurs from low to high income countries, where there is
low unemployment and where the number of migrant increases if the cost of moving is
considerably low or the expected income is larger than the cost to move.
The neoclassical model of factor mobility, which emphasizes labour migration, advocates
the benefit to be derived from migration for both the source and host countries.
Theoretically, the countries should not be worse off. The relative scarcity of labour in the
host or receiving country, as evidenced by the wage differential between countries would
be addressed. It al so suggests that the overabundance of source country would be
relieved (Todaro 1985). Thus the free movement of labor should benefit both countries
since in addition to the provision of scarce labour to fill the gap in developed countries,
and providing higher wages for labourers than in home country, it would contribute to a
reduction in employment for the source countries as well as the provision of remittances.
International migration is thought to assist in the provision of solutions for structural
problems and imbalances in developing countries (Todaro 1985). Five major benefits can
be identified. (1) a reduction in domestic unemployment as already identified; (2) the
availability of remittances to families of migrants. This often results in increased local
consumer demand and savings. The resultant provision of “incentive and source of
foreign exchange for capital formation.” This allows for sustained economic growth
(Todaro 1985). (3) Outflow of labour, which would “raise land - labour ratio”,
contributing to increased capital formation (Todaro 1985). This would lead to an
improvement in labour productivity; an increase rural income and stimulation of rural
growth; (4) returning migration bring skills which would contribute to increased human
capital formation preclude/negate the need for expensive domestic training programmes;
and (5) enhancing income distribution in the source country.
It can be agreed that migration often benefits the individual migrant who receives higher
wages and higher standards of living. However controversies exist regarding the real
benefit to the exporting country (Todaro1985). The realities of developing countries
determine whether the benefits are illusory.
The illusion emerges because skilled labourers often migrate, not unskilled, which results
in a brain drain. This presents another problem for these countries. Also, the impact of
remittances varies across countries based on each country’s ability to “absorb excess
demand through domestic production.” Low-income countries, which experience
“repeated inflationary spirals and excessive consumer spending in the absence of real
economic growth are represented here. Remittances do not necessarily promote savings.
They may also lead to a decline in the agricultural sector as a result of excessive
migration, which may occur. A change in status among other things may result in the
decision to “leave the land”. This could result in a decline in the sector and allow for the
availability of land and scarce labour for production. The returning migrant thesis
advances two assumptions – that the migrants were able to obtain work in the receiving
country, and the work undertaken involved greater skills than possessed at home. In
addition, it also assumes that these migrants return home to impart skills. Problems
involve the applicability of skills to technology at home and the possibility of being overskilled
in relation to domestic production. Finally, arguably, migration usually occurs
within the middle class (though not always), making them better off. Usually the poorer
individuals are unable to afford recruiter fee, airfare and other financial costs involved.
Within this context remittances sometimes fuel domestic price inflation in food staples
and consumer household goods.
A paradigm shift attributes migration to market failure in host countries (Kubursi 2006).
Markets may be incomplete, imperfect, inaccessible or in some cases non-existent.
Against this background, family members are sent abroad for risk mitigation and access
to capital. International migration becomes attractive when wages and opportunities
greatly exceed that of the sending country (Stark 1991). Within this context the individual
ceases to be the level of analysis and is replaced by the society or the household.
Emphasis is now placed on relative income determinants instead of absolute income
correction. Relative deprivation rather than wage is now advanced as responsible for
driving the migration process (Stark and Taylor 1989).
The Segmented labour market approach to migration posits that the structure of
developed economies necessitates and facilitates migration. Immigration responds to the
demands forces existing in developed countries. These forces result from structural
imbalances in these economies, which gives rise to the creation of segmented labour
markets. The dualistic nature of developed markets provides the framework for this
possibility. The primary market consists of well-paid, secure positions, which are filled
by nationals. The secondary market offers remuneration for low-wage work, and
migrants are usually recruited to undertake such activities, which, while required for the
efficient functioning of the economy are shunned by nationals. This obtains as a result of
the hazardous and unpleasant working conditions of the secondary market, which
coexists with the primary market. According to Kubursi (2006), the immigration policies
of the United States are reflective of the entrenchment of these segmented labour
markets.
The World Systems Theory advocates that migration results from the entrenchment of
global capitalism. Wallerstein (1979), the main protagonist of the theory identifies the
world as being divided into core (rich nations) and periphery (poor nations). The
characteristics of the core include democratic governments; high wages; the importation
of raw materials, the export of manufactures, high investment and welfare services. The
periphery reflects non-democratic governments, the exportation of raw materials the
importation of manufactures, below subsistence wages, and the absence of welfare
service (Wallerstein 1979). The structural imbalance in the world system is a necessity,
which allows the rich countries to become richer at the expense of the poor. Movements
thus emanate from the periphery to the core, resulting from the structural economic
problems created by developed countries. These in turn create the push factors in
developing countries. In recent developments, globalization has witnessed the destruction
of “non capitalist structures and patterns of social and economic organizations (Kabursi
2006:11-12). The collapse has resulted in the loss of “secure patterns of living and
working conditions” and the workers have thus become potential migrants and the
creation of a very large supply of highly mobile workers in developing countries and
economies in transition (Rumbaut 1991). The situation created by globalization has led to
a reduction in demand for unskilled labour and the resultant decline in wages, as against
an increase in demand for skilled labour and a corresponding increase in wages.
An analysis of the theories reveal different approaches to the study of migration but at the
core, the basic principle is the push-pull factor. Nurses migrate fundamentally to earn
more money, access education and advanced technology skills provide for their families
and improve their overall quality of life (Xu and Zhang 2005). It is argued that these
opportunities can be accessed in the countries to which they migrate. It can also be
concluded that given the chronic shortage of nurses globally, migration of this group will
be perpetuated until the gap is closed. What the theories do not address are policies,
which can be implemented to address this crisis situation. Thus while the theories are
helpful in providing an understanding of migration movements within broader economic
and political contexts, they fail to offer solutions to the problem, although policy
prescriptions can be designed according to the theory which provides more relevance to
the particular country’s experience or reality.
THE CARIBBEAN CONTEXT
Migration has always been a reality of the Caribbean experience. For the most part this
migration involved and still does the movement away from the Caribbean for workrelated
purposes and the search for improved living conditions (Hewitt et al 2007). The
last five decades have witnessed the movement of highly skilled and semi-skilled
professionals from the region to “richer” developed countries. Traditionally nurses from
the Caribbean have migrated to the United States, Canada and the United Kingdom. What
has resulted there from is a brain drain, which has detrimental impact on the economies
of these countries, as in most cases skills training and education were heavily subsidized
by the respective governments. The loss as a result has to be borne by the governments,
as policies have not been put in place to recover these losses and while subsidized
training continues in some countries. For example, figures from the Ministry of Health in
Jamaica indicate that 58 percent of nursing positions were vacant and 1,521nurses were
required to be trained in order to fill existing vacancies. The government will need to
train 2,830 nurses between 2003 and 2008, but only 2055 nurses are expected to graduate
by 2008 (Hewitt et. al 2007).
It must be understood that “Migration is deeply embedded in the development of nursing
in the region (Hewitt, et al 2007) Many of the nurses in the Caribbean received their
training in developed countries, for example, the United Kingdom, Canada, The
Netherlands and the United States. Previously, however the trend was that some of them
would return to enhance the development of the Caribbean programmes. However, in
recent years, the emphasis has been on permanent migration. It has been argued (Lindsay
and Findley 2001) that approximately two-thirds of the nurses trained in Jamaica has
already left. Some of these nurses were trained by the Jamaican government, and while
they were required to sign a bond, which is usually no guarantee that the trained nurses
will remain and honour their obligation. In many cases the nurses served their required
time and left or reimbursed the money owed and left. While that may be commendable,
the necessity is for the nurses to remain in order for the health sector to function
adequately.
One of the major problems facing the health sector in the region is the aspect of
permanent migration, and this renders the situation difficult to address. There are no
strategies in place to address the migration of individuals whether professional or
unskilled. Additionally the government or nursing administration cannot infringe on the
constitutional rights relating to a person’s freedom of movement for whatever reason as
long as it falls within legal boundaries. The receiving country’s immigration policies
would respond to that situation, that of ebbing the flow of nurses to their shores. In fact
the decision of a country to admit individuals and the amount is a function of out comes
of public policy discussions. It bears very little relationship to the economic and
demographic conditions of the sending countries (Kritz 1988).
As has already been stated the developed countries exploit the situation in the Caribbean
and other regions as a result of their need to address the shortage of nurses in their own
countries, hence as long as they satisfy the requirements of the particular country there is
nothing to prevent them from taking up permanent residence in that place. Thus, while
the brain drain continues, exacerbating the already disastrous situation in the Caribbean,
the governments of the region are hard pressed to find solution to address these problems.
One such response is the employment of nurses from other regions (Africa and Cuba, for
example). While this offers temporary respite, it serves to heighten the problem and has a
two-fold effect. Firstly, it creates the same problem in some of these economies,
especially those that do not and are unable to train an adequate amount of nurses to
address their need and that of other countries. There is also the great language barrier that
attends this employment of these individuals. In addition to this there is the question of
qualification and certification.
The spate of migration of nurses from the region that has now been described as alarming
(CARICOM 2007), created challenges for the various authorities involved. Some of these
challenges include: the “relative numbers of nurses leaving the region”; the constant,
“unrelieved” outflow of nurses; the loss of more experienced nurses; the loss of nursing
educators; the lack of educational capacity to replace lost nurses; the inability to
assimilate returnees; the image and work conditions for nurses in some countries in the
region; the highly aggressive recruitment of nurses by companies representing employers
from countries experiencing shortages; increased demand for quality health care by
nationals within CARICOM; increasing intensity and complexity of work (Hewitt et. al
2007).
While the problem is a pressing one globally, it is viewed as severe in the Caribbean
given the small size of the economy and the inability of these countries adequately
address the issue and at the same time to maximize benefits from such situation.
Countries such as Cuba and the Philippines have implemented managed programmes to
address this situation.
The Cuban model, developed in the 1980s emphasizes 4 complementary areas in the
export of health services (Chanda 2001). As regards Mode 4, the movement of health
service personnel, Cuba targets selected developing countries, where they provide
advisory and consultancy services. In addition, trained personnel – nurses and doctors are
deployed to these countries under specific arrangements with the governments of these
developing countries.
The Philippine model has at its foundation the Philippines Overseas Employment
Administration that is responsible for the control of the migration process. The process
includes the marketing of the domestic labour force, negotiation of agreements for the
workers, controlling illegal migration, regulation of domestic recruitment practices and
information dissemination to protect workers’ interests. The POEA is promoted as a
model to be emulated as it represents an example of a state- managed development policy
in which workers are trained for employment abroad. Unlike many developing countries
such as Jamaica and South Africa, most nursing education in the Philippines is privately
financed (Thomas et. al 2005).
A POLICY RESPONSE
Given the critical shortage of nurses in Jamaica, and the wider Caribbean, the region has
responded with a long-term strategy to address the problem. The Managed Migration
Programme was conceived in 2001, following a review by PAHO/CPC as regards the
“scope and impact of nurses’ migration in the Caribbean” (Hewitt et.al 2007). It reflects
to a large extent the Managed migration Programme implemented in Jamaica, and is
defined as “a regional strategy for retaining an adequate number of competent nursing
personnel to deliver health programs and services to the Caribbean nationals” (Deyal
2003: 27).
At the core of the programme are two fundamental values: nurses possess rights as
individuals to the freedom of movement within and beyond the region; and the rights of
all to access the highest quality health service and programme. Managed migration seeks
to proactively address the issue of migration of health workers and provides the stimulus
and a broad framework for governments of the region as well as other stakeholders to
implement programmes to respond to the crisis.
The Programme focuses on recruitment, retention, deployment and succession planning
for nursing within the Caribbean as well as active partnership with multiple stakeholders.
There are six critical areas – terms and conditions of work; retention and training; value
of nursing; utilization and deployment; management practices and policy development. It
provides the framework within which the various governments of the region as well as
stakeholders are able to cooperate in developing “interventions” for the management and
moderation of the migration of nursing professionals. As reflected in the programme, the
governments are not opposed to the migration of skilled professionals within the context
of the provision of mutually beneficial returns for both developed and developing
countries. The full minimization of cost and maximization of benefits to both host and
source countries as well as the professionals can only be realized if effectively managed.
(See Appendix I for text of Managed Migration Programme)
While the Programme represents a region-wide, “multi country, multi sectoral,
multidimensional” initiative, respective governments have implemented strategies,
suitable to their own countries and needs, to manage migration. Also emphasis has been
placed on examining the “potential for macro management of migration though trade and
multilateral agreement relating to nursing service and education” (Hewitt et .al 2007).
Some of the strategies are listed below:
St Vincent has embarked on the establishment of bilateral agreements for compensation
from the institutions recruiting Vincentian nurses. Emphasis here is on training nurses for
export. Employers from the host country would be required to pay approximately US
$17,000 for each nurse. The sum paid would be reinvested in the economy to enhance
nurse training (Hewitt et. al 2007).
The Jamaican scenario indicates temporary migration in which the nurses seek
registration to practice in Miami, US, for two weeks per month and work in Jamaica for
the remainder of the month. This facilitates skills development, increased earning and
assisting with staffing needs in Jamaica.
As regards Grenada and Antigua, which emphasize regional cooperation, there is an
agreement between the two Ministries of Health. The Grenadian Government has
“opened up its excess training capacity to nursing students from Antigua.” Under this
agreement, Grenada will providing training for 20 Antiguan nurses at a minimal cost.
These nurses will then be able to return home to practice, given the facilitation through
the Regional Examination for Nurses Registration and the Common Nursing Education
Standards in the Caribbean.
Through a partnership between the Government of St. Kitts and foreign investors, the
government has established an International school of Nursing, the International
University of Nursing (IUN). This is an offshore school, aimed at responding to the
demands of the global market for trained professional nurses. The government envisions
a target of 1,500 individuals per year, sourced globally, with China initially financing the
first 150 students. Full scholarships are provided for selected nationals of ST. Kitts, and
bonding requirements are put into effect. Currently the IUN of ST. Kitts and the Clarence
Fitzroy Bryant College (a government -funded community college in St. Kitts have
entered into partnership for the enhancement of nursing education (IUON 2008).
In 2003, an initiative – The Homecoming Programme - was undertaken in the Caribbean
where Caribbean nurses residing other countries were invited to return home to
participate in an exercise in which they shared expertise and volunteered to work in
certain areas. Possibilities of joint ventures for the development of nursing education and
practice were also explored.
Two other strategies involve the international recruitment of nurses using the health and
tourism model and the temporary movement of skilled nursing professionals between
Canada and the Caribbean (Hewitt, et al 2007). The former programme deals with the
attempt to recruit nurses from developed countries for a limited period of time.
Remuneration for these recruits would correspond to that of local nurses. The latter
programme attempts a bilateral agreement in which migration would be channeled into a
temporary movement of personnel. The proposal includes the provision of incentives for
individuals who return after their tenure and disincentives for those who overstay. The
two major policy principles which emerged from this proposal are those of incorporating
migration issues in the overall socioeconomic development agreements and the effort to
package the nursing profession both as an independent service and including a “cutting
edge health care system” (Hewitt et al 2007).
It should be noted that although the GATS does not provide any “legal impediments” to
prevent respective governments from implementing strategies to prevent qualified staff
from migrating, nothing has been attempted in this regard. There are currently no
disincentives that would make it financially unattractive for nurses to leave immediately
after training. In fact currently the new policy now requires trainees to finance their own
training. Thus no financial burden accrues to the government. However there are no
obstacles which would prevent these individuals from seeking employment elsewhere,
since there would be no obligation to the respective governing authorities. This situation
however allows for ease in the recruitment process and would negate any attempt on the
part of the government to recover the cost involved in training the individuals.
AN ANALYSIS
Much has been written about the critical shortage of nurses in the Caribbean and its
impact on quality health care in the region. Much has also been researched on the reasons
for the migration of nurses from the region, the push factors and the pull factors.
Interestingly, the migration of nurses from the region of nurses from the region was
brought to attention from as early as the 1960s as highlighted at the first Commonwealth
Medical Conference in 1965 in which nursing services was discussed as one of the health
priorities. It focused on three (3) critical areas – the shortage of nurses in most
Commonwealth countries; the desire on the part of nurses to obtain training or work
experience in overseas markets; and the need to ensure the return of skilled workers once
training had been completed ((Parris 2001). The recommendations by a WHO Expert
Committee for the break away from traditions and existing stereotypes and the need to
implement major changes to meet the needs of the rapidly changing society were largely
ignored (Parris 2001).
The managed migration programme embarked on in the Caribbean after approximately
40 years, is established on six pillars: Terms and conditions of work; recruitment,
education and retention; value of nursing; utilization and deployment; management
practices; and policy development and health science research. The programme is
intended to “facilitate the recruitment of labour… while limiting adverse effects, so as to
protect the domestic market” (Deyal 2003:27). Some countries in the Caribbean region
have opted to train for export (on a rotational basis) with a view to regulating the export
of labour and mitigate the negative effects being experienced in some countries (La Rose
2002).
Within this broad framework, individual countries have designed country-specific
interventions. The policy direction and enabling actions are comprehensive enough to
allow for the development of concrete action and the completion of strategies. However,
while it focuses on the increase in training capacity, recruitment and retention of nurses,
it does not address the fundamental reasons advanced for migration, especially the push
factors, which underlie the structural problems in developing countries. Countries like
Jamaica, which experience a net outflow, must seek to comprehend why such a
phenomenon occurs. The impact is immediately obvious- the reduction in the delivery of
quality care for individuals requiring health care and the brain drain, which creates this
problem.
While migration of nurses is an ongoing process, which started before the liberalization
of trade in services, it can be argued that this very process of liberalization has
exacerbated an already critical issue. Many governments in the Caribbean undertook
liberalization activities, which have removed most of the barriers to trade in this area.
This includes the permission of recruiting agencies to enter uninhibited. It has already
been established that developed countries exploit the push factors in developing countries
in an effort to address the shortage in these developed economies. Currently in Jamaica,
the recruiters are not regulated, and data is unavailable as regards the amount of recruiters
that visit annually. Neither are they required to pay a fee to advertise their programme or
undertake recruitment activities.
This Managed Migration Programme recognizes the fact that migration is a part of the
Caribbean reality, and especially unmanaged migration of nurses, as has obtained over
the years cannot continue unchecked, as a result of the detrimental effect on the health
care services of individual countries. It also recognizes the rights of individuals to free
movement and thus attempts to find solutions that would encompass both ideals.
Strategies that have been tried in the past, such as bonding have not worked, as has
previously been stated, especially since migration offers the possibility of buying out of
the bond.
The success of the managed migration programme in the Caribbean is dependent on the
participation of ‘a wide cadre of stakeholders at different levels’, both within and outside
the region. Success is currently difficult to determine, as there is no comprehensive data
on many of the strategies; for example, while it can be said that enrolment has increased
in the various nursing schools, there is no central body, which can provide the data, and
the reason for the increase cannot be readily ascertained. There is no causal relationship
between the increase in enrolment and the emphasis on the MMP.
Given the global shortage of nurses and the corresponding need to ensure quality care in
both developed and developing countries, the most pressing need today seems to be the
recruitment and training of nurses for global supply. The Caribbean as well as other
developing countries is well poised to take advantage of such a situation. It should be
remembered that these countries have a comparative advantage in labour, and should be
able to maximize benefits from or exploit this situation. Thus policies should be put in
place to develop programmes to train for export. Thus, countries can enjoy the best of
both worlds. This introduces new problems and demands on these countries. One major
issue is that of capacity. Currently the Caribbean lacks the facilities to increase intake to
any great extent, although a PAHO study (Thomas et .al 2005) indicates that the
Caribbean possesses the capacity for increased enrolment. Although the implementation
of the programme has seen a tremendous increase in the number of applicants to the
nursing profession (Hewitt 2008), the motivation cannot be determined, as previously
stated. Success in this area, therefore necessitates massive investment in training
infrastructure, the upgrade of clinical facilities; building the capacity of nursing educators
and improving the quality of training to meet the demands of the respective countries and
the global market (Hewitt, et al 2007:1370).
This will require the participation of the private organizations, recruitment agencies and
other interested stakeholders to provide resources for the construction of larger and better
health care facilities to support clinical training of more nurses (Hewitt et al 2007).
Arguably, reliance on investment as a strategy to develop the health sector is a viable
option. In fact it goes in tandem with a need for increased training capacity. Given the
fact that it is associated with resource inflows, it could provide the resources required for
the development of the sector and assist in the transformation of the economy. This could
also address some of the push factors inherent in developing economies. According to
Adiung and Carzaniga (2001), foreign investment in the health sector can be seen as a
positive transfer of resources, extending beyond the sector. Spin off effects could extend
to growth of the economy, income and employment in related industries. While
difficulties exist in proving developmental benefits, they should not be considered
“economically irrelevant” (Adiung and Carzaniga 2001) Counterpart responsibilities on
the part of the respective governments include the provision of benefit as regards tax
status, work permits, immigration and foreign exchange accounts.
The other problems associated with a decision to train for export include training and
certification. An examination of the situation at the international University of Nursing
reveals that there are certain shortcomings that must be addressed for the programme to
function efficiently. These are fundamental problems that affect the outcome of the
programme. Training procedures differ from country to country and from region to
region. It has to be decided therefore which standard will be utilized, what teaching
method and where the practicum will be undertaken. Currently the programme
experiences problems of this nature, as regards the inability to find places for the students
who must have clinical experience in order to complete the prescribed programme.
The other problem relates to certification as the standards of the Regional nursing council
differ from those of other councils and regions. What obtains therefore is the problem of
deciding what standard should be used. Currently there is no mutually agreed standard
nor is there a global certification body, hence all nurses must meet the requirements of
the country to which they migrate. There would be needs for this to be addressed for the
proposed programme to achieve its objectives.
Although the agreement under the GATS require that certification and training should not
be used as barriers to trade, most countries have identified in their schedule of
commitment the need for migrant workers to be trained and /or certified according to
their standard. This, interpreted within the context of the proposed programme to train for
export, is a major problem in the absence of the general certification body.
Currently this does not pose a problem for those migrating to the United States as what is
required is for the migrants to pass the State Board Examination. Under the proposed
scheme this would or should be redundant since as an international programme it should
respond to the needs of all countries requiring the services of these nurses. There is also
the need for a central accreditation body to facilitate this process. Essentially, several
initiatives are required within the context of the GATS. These include multilateral
cooperation on immigration, labour-market policies, professional standards, mutual
recognition and licensing norms (Chanda 2002). Also important is the need for
discussions on the movement of health personnel in multilateral and regional fora
(Chanda 2002)
Respective governments, stakeholders and international bodies have all undertaken
studies to examine the factors, which push nurses out of the region. They have also
embarked on programmes to address the shortage of trained professionals to reduce the
shortfall. While these programmes can be considered successful to an extent in that more
nurses are trained, the problem remains, that of the migration of nurses. It cannot be
ascertained the number of nurses who leave after the completion of the programme, and
those who utilize nursing as a vehicle for mobility. Unless the fundamental problems of
these developing countries are addressed, that of the structural imbalance which exist,
these countries will continue to experience marked migration and even within the context
of training for export, there cannot be any guarantee that enough will remain to address
the existing need since the push and pull factors are overwhelming, even in the face of
expressed desires to remain. The reality of developing countries, and more specifically
the Caribbean region and the devastation in the health sector must be taken into
consideration, and must be a part of any long term development plan in order to provide
quality care for the citizens of the region.
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APPENDIX – Managed Migration Programme
Critical Area Strategic Activities Partner Progress
Recruitment,
Retention,
Education and
Training
*Caribbean Nursing
Campaign
*Mentorship Programme
*Social Marketing
* Nursing Exchange
Programme
· Homecoming
· Cadet Programme
· Johnson& Johnson
· COMSEC, UK; RNB
*Videos and posters were produced by
Johnson and Johnson and distributed to
every country participating
*Funds donated by the Commonwealth
Secretariat (COMSEC) for the
mentorship Programmes
Terms and
Conditions of
Work
*Healthy Workplace
*Ratification of ILO 149
and 157 nursing personnel
convention
*Training Programme
(SOLVE)
UK Department of Health
PAHO, RNB
Information Package on Healthy
Workplace distributed to member
countries
Utilization and
Deployment
· Workload
Measurement
System
· HR Data
Management
PAHO/CPC, RNB, Health
Canada
System in place in the British Virgin
Islands, ST. Vincent and the Grenadines
and Dominica
Value and
Recognition
· RNB website
· Nursing Research
· Nurses appreciation
· Participation in
Prize giving and
Nurses’ Graduation
· Year of the
Caribbean Nurse
Lillian Carter Center for
International Nursing, Emory,
USA
CNO, NNAs
Johnson& Johnson, USA
CNO, RNB, PAHO,
Johnson& Johnson
Year of the Caribbean Nurse
Celebration 2003-2004 in member
countries
Compendium of the outstanding
Nursing Projects and programmes
Education and
Training
· Training capacity in
Nursing schools and
Colleges
· Distance Education
programme in
Nursing
· Nursing Scholarship
Department of Advanced
Nursing Education, UWI
Health Canada, PAHO
Mavis Henry Foundation
Study on training capacity completed
CNO Conferences:
2002 – St. Kitts
2004 – Curacao
2006 – Commonwealth - Bahamas
Management
Practices Health Sector Reform Policy
· Regional Managed
· Migration Plan
· Attachment and exchange programmes
· Leadership for Change (LFC) training
(National and Regional)
· Magnet Hospital Programme
· Consumer Outreach
Other Opportunities
· Mode IV Commonwealth Secretariat in
Barbados, March 30-32, 2005
‘Canada Bound’
*RNB, PAHO, CARICOM
*RNB, ICCIN, Health Canada
*ICN, CNO, NNAs
PAHO, LCCIN, ANCC, St
Josephs Hospital (Atlanta)
First Caribbean Bank
Endorsement of Managed Migration
Programme by CARICOM Health
Ministers
*CNO, LFC in Barbados, Jamaica,
Bahamas, St. Lucia
*6 New ICN Certified LFC Trainers
for the Caribbean
*Workshop held in Jamaica
November 2003. Participating
Countries: Jamaica, British Virgin
Islands, St. Kitts, and Suriname
*CNO Outreach In Barbados (Unsung
Heroes Award)
Health Canada
CNO – President Presented Paper on
Migration of Nurses: Issues from the
Hospital Floor
Source: The Jamaican Nurse, 43 (1&2) 2005 17-18